NHS 24 QUALITY FRAMEWORK 2019 2021...Juran Trilogy of Quality Planning, Assurance and Improvement.9...

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NHS 24 QUALITY FRAMEWORK 2019 2021 DELIVERING QUALITY HEALTHCARE, ADVICE AND INFORMATION TO SCOTLAND NHS 24 Executive Lead: Chief Executive Officer Issue Date: February 2019 Status: LIVE Version: 1.0 Review Interval:2 Years

Transcript of NHS 24 QUALITY FRAMEWORK 2019 2021...Juran Trilogy of Quality Planning, Assurance and Improvement.9...

NHS 24 QUALITY FRAMEWORK 2019 – 2021

DELIVERING QUALITY HEALTHCARE, ADVICE AND INFORMATION TO SCOTLAND

NHS 24 Executive Lead: Chief Executive Officer

Issue Date: February 2019 Status: LIVE

Version: 1.0 Review Interval:2 Years

CONTENTS PAGE

Foreword 1

Introduction 2

Purpose of Framework 3

Aims Framework: Key Strategic Outcomes 4

Putting People at the heart of quality 4

Quality Ambitions 5

NHS 24 Values 5

Creating the conditions 6

Quality Management System 8

Quality Assurance, Control and Improvement 9

A learning system and supporting infrastructure 12

Delivering the plan 13

Appendix A 14

Appendix B 15

Appendix C 16

Acknowledgement 17

References 18

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FOREWORD

“The overarching aim of NHS 24 is to ensure that all service users across Scotland

experience consistently high quality services to a standard that all of us in NHS 24

would be proud to provide. To do this we have a duty to ensure that all staff know

they are supported, empowered and valued to deliver these services.

In making quality the focus of our learning organisation, we can meet the challenges

presented by rising demand and limited resources, to deliver the best possible

services to the people of Scotland. We will achieve this with a focus on measuring,

monitoring, assurance and continuous improvement.

This framework outlines a supporting structure to guide NHS 24 on the pathway to

delivering those high quality services and empowering our staff to lead and deliver

on the Quality agenda.

This can only happen by putting our service users, staff and stakeholders at the

centre of everything we do, working together as a team, ensuring we have the data,

resources, engagement and support required to continue the delivery of excellent,

high quality care”.

Angiolina Foster CBE Chief Executive Officer, NHS 24

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INTRODUCTION

NHS 24 is the national provider of digital and telephone based health and care

services for Scotland. Providing people with access to information, care and advice

through multiple channels, working in collaboration with partners, the public and staff

to co-design services using technology and a digital first approach to sustainable

service development and delivery.

The NHS 24 Strategy, 2017-20221 describes a commitment to “helping to deliver a

healthier Scotland by connecting people to health and care advice, information and

support 24/7”. The strategy supports the development of an integrated health and

social care system which has a focus on supporting people to live longer healthier

lives at home or in a homely setting aligned to national health and care strategies to

build a stronger organisation. One of the key objectives to ‘Delivering a Healthier

Scotland Together” 1 is improving services to ensure the delivery of the

organisational vision of continuous quality, safe, effective and person-centred care

by connecting, caring and collaborating.

This Quality Framework underpins the delivery of services, which are assured,

monitored and continuously improved. Developed in alignment with the Healthcare

Improvement Scotland Quality Framework2, Quality Management System3 and NHS

Scotland Quality Strategy 20104, the framework also adheres to the principles of the

European Foundation for Quality Management (EQFM) Excellence Model5 which is a

framework that aims to improve organisational excellence in delivering quality

outcomes.

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Diagram 1: NHS 24 Key Objectives, ‘Making it Happen – Our Key Priorities.

PURPOSE OF FRAMEWORK

NHS 24 is committed to delivering world-leading, high quality, innovative services

that are safe, effective and person-centred. NHS 24 is a quality driven organisation

that places people at the heart of everything it does, with a focus on achieving a

healthier life for all. Through commitment to a culture of quality, NHS 24 aims to

deliver the highest standards of health and care services for the people of Scotland.

This framework has been commissioned by NHS 24’s Chief Executive Officer and

has been informed by contributions from Executive Directors and Senior Clinical and

Non-Clinical leads throughout the organisation. Quality is the responsibility of all

NHS 24 staff and everyone has a role to play in delivering safe, effective person-

centred care. NHS 24 aspires to deliver standards of excellence in respect of care,

advice and information offered. These expectations can be realised with a

strengthened approach to quality, where services are monitored, assured and where

opportunities are grasped to continuously improve.

This framework sets out the NHS 24 modernising approach to quality and will

support the development of the associated delivery plan for the identified quality

indicators and priorities. NHS 24 will also enhance the current systems of assurance

to ensure the recognition of risk, relevant implementation of mitigation and resultant

areas for improvement.

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AIMS OF FRAMEWORK

Key Strategic Aims 2019 - 2021

NHS 24 has identified four key aims to describe what successful delivery of this

framework will achieve by 2021, these aims are to:

maximize the quality of NHS 24 outcomes for the population of Scotland by

building upon existing Quality Management structures

increase the measurement and monitoring of services to demonstrate

organisational integrity and assurance both internally and externally on the

quality of services provided

take a consistent, evidence-based approach that applies the recognised

methodology for improvement for all new services, service changes,

improvements or transformations delivered by NHS 24

ensure that Stakeholder Engagement will underpin the model of delivery,

ensuring the conditions are set for continuously improving, and that our staff

have the education and tools to support them in delivering against the aims of

the NHS 24 strategy.

PUTTING PEOPLE AT THE HEART OF QUALITY

NHS 24 has a duty to provide assurance to the Board and the Scottish Government

that the services provided are of the highest quality. It is vital that at the centre of all

quality approaches is an engaged and active stakeholder group.

To consider the impact on all service users, staff, carers and families the vision

related to this framework is that people will be involved in decision making and be

active partners in all quality related work, including assurance, planning and

improvement. Central to a successful delivery of this framework will be working

collaboratively and in partnership with all stakeholders, including service users, staff,

partners and trade union representation. In Practising and Realising Realistic

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Medicine and delivering against the principles of value-based healthcare, NHS 24

will aim to improve quality by tackling unwarranted variation, harm and waste and

share knowledge with a realistic approach to population health.6 A key deliverable of

this framework will be to develop a sustainable stakeholder engagement plan in

relation to quality of services and outcomes delivered.

QUALITY AMBITIONS

NHS 24 services are underpinned by the six Quality Ambitions outlined in the NHS

Scotland Quality Strategy 20103 to deliver safe, efficient, effective, person-centred

care that is timely and equitable.

NHS 24 believes that the shared pursuit of these quality ambitions will continue to

make positive impacts on safety, efficiency and productivity to improve outcomes for

the people of Scotland and that the framework in conjunction with the NHS Quality

Ambitions will drive NHS 24 to deliver the highest quality of care and services to the

people of Scotland.

NHS 24 VALUES

NHS 24 has adopted the NHS Scotland Values of Care and Compassion, Dignity

and Respect, Openness, Honesty and Responsibility, Quality and Teamwork, which

are the foundation on which quality services are built. They underpin the

organisational purpose, provide focus and context for the improvement of services

and guide individual and team behaviours. Embedding these values will help to

make the vision of improving the quality of services delivered a reality. To do this

there is a requirement to demonstrate the values in the way the organisation works

and how people are treated. It is everyone’s responsibility to live the values. NHS 24

will encourage all stakeholders to contribute to, co-design and deliver upon the

framework aims. Aligned to the NHS 24 values and philosophy, all of the actions

undertaken as part of this framework will enable and actively promote equality,

human rights and commit to reducing health inequalities

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CREATING THE CONDITIONS

NHS 24 is committed to strengthening a connected, cross directorate infrastructure

and building the will to deliver the ambition of placing quality at the heart of the

organisation. The components include:

Leadership and Behaviours – To bring the culture to life, the NHS 24 values

must be demonstrated in day-to-day behaviours demonstrated by the

organisations’ leaders, who should have clarity of vision and purpose of how

to influence, support and deliver upon the strategic priorities. Key learning

from the Vale of Leven Inquiry7 was that quality, monitoring, scrutiny and

improvement work should be from Board to Service Delivery and Service

Delivery to Board and that leadership behaviours should reflect the

organisational values. A culture of compassionate leadership will allow staff

and service users to feel safe to discuss and raise issues related to quality of

care

Improvement and innovation – NHS 24 will use a consistent digital first

approach to improvement throughout the organisation that reflects all stages

of the improvement journey and that this approach will apply to continuous

daily improvement as well as large-scale transformational change

Evidence – NHS 24 services will be based on the best available evidence

from a variety of sources. It is proposed that a centralised structured means of

collating evidence to enhance quality will be developed

Communications and Engagement – To support the approach NHS 24 will

implement a comprehensive communication and engagement plan. This will

promote the organisational purpose and quality ambitions. Furthermore this

will develop partnerships, collaborative working and co-design opportunities

with service users, the public, staff, professional partners, third and

independent sector, carer organisations and elected representatives

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Information – NHS 24 collects a range of data on the services provided. This

information supports the measurement of how effectively the NHS 24

approach to quality is applied to services. It also provides the Board with

assurance that the organisation is planning and delivering quality in line with

the organisational strategies and as a result is able to deliver improvements to

care and services. Data is a crucial element to understanding the issues

requiring improvement as well as vital to demonstrate the success of

interventions, the development of the data strategy within NHS 24 will be vital

to supporting improvement work

Knowledge and skills – NHS 24 expects staff to demonstrate the attributes

of a caring, knowledgeable and skilled workforce, in delivering and meeting

the expectations of service users. Aligned to the strategic aims as set out in

the Scotland’s Digital Health & Care Strategy8, NHS 24 is committed to

ensuring that in order for staff to enable, connect and empower people they

are provided with the appropriate knowledge, skills and confidence to deliver

high quality services on a day to day basis, whilst continuously improving

those services. NHS 24 is committed to establishing an infrastructure that

builds the organisational capacity and capability to deliver against the

strategic priorities.

In summary, the NHS 24 approach to quality provides a clear outline of the vision,

mission, objectives and values of the organisation, to assist in the delivery of high

quality, person-centred care. To provide clarity the Healthcare Improvement

Scotland 2018 Quality Management System Framework has been adopted as shown

below:

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Diagram 2: High Level Quality Management System Framework – Healthcare Improvement Scotland

QUALITY MANAGEMENT SYSTEM

Historically a Quality Management System was built on the principles of the J.M

Juran Trilogy of Quality Planning, Assurance and Improvement.9 This demonstrates

organisational systems and processes are in place, which provide evidence based

assurance around safe delivery of services and where improvements can be made.

Health care evidence is used to assist staff to make decisions about health and care

services.

In 2018, Healthcare Improvement Scotland updated this philosophy and created a

Quality Management Framework (Diagram 2). This builds on the traditional

triangulated approach to include important principles such as co- design\co-

production, leadership values and purpose. At the centre of this model is a learning

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system and the most prominent feature of NHS 24 Quality Framework is that it

embraces culture of learning and improving and delivering the highest quality

outcomes for our service users. NHS 24 will embrace and adopt the Quality

Management System approach and this will underpin and inform all aspects of

quality.

QUALITY ASSURANCE, CONTROL AND IMPROVMENT

Quality Assurance

Is defined as a procedure or set of procedures intended to confirm a service meets

specified requirements. The focus is on ensuring and providing confidence that

quality requirements will be fulfilled. This confidence is twofold, internally to Senior

Management and externally to service users, partners, regulators and other key

stakeholders.

NHS 24 assurance is provided through internal processes to demonstrate the quality

of services and care offered. This assurance is provided via the implementation and

updating of policies, processes, systems and training. Currently within NHS 24, there

are effective systems and processes in place to offer the required assurance. These

include:

Service Users, Staff and Partner feedback structures

Clinical and Operational Processes

Clinical Audit

Adverse Incident Reporting System

Call Consultation Review

Patient Safety Leadership Walkrounds

Corporate, Staff and Clinical Governance systems, processes and reporting

structures

Weekly organisational performance reports to Scottish Government

Public Partnership Fora

Area \ Regional Partnership Fora.

Whilst many territorial Health Board partners currently undergo external scrutiny and

assessment to monitor the quality of services and offer public assurance on the

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quality of service provision NHS 24 currently has limited external assessment via

Scottish Government. This framework will develop on the element of external

assurance and seek to create new external assurance pathways aligned to

Healthcare Improvement Scotland’s Quality of Care approach.

Quality Control

Whilst similar to Quality Assurance, the principles of Quality Control are set within

the ideology of a system to maintain standards by testing the services being

delivered against set criteria. The focus is on an organisation fulfilling its quality

requirements, therefore Quality Control relates to the inspection aspect of quality

management. This is the process of monitoring, measuring, examining and testing to

gauge characteristics of a service and the comparison of these with specified

requirements to determine conformity. It is vital to embed mechanisms into services

and teams to allow them to detect variation from agreed standards. NHS 24 has

current control measures in place, which include call review, key performance

indicators and management of adverse events and complaints. NHS 24 aligns to the

Vincent Framework for measuring and monitoring of Safety10 and views care within

the five dimensions of this which offers a comprehensive and rounded picture of an

organisation’s safety.

Whilst there are effective systems and process in place, there is scope to develop

these further and adopt key learning from national inquiries. The Francis report into

Mid Staffordshire NHS Foundation Trust11 called for organisations to have standards

and methods of measuring compliance, which focus on the effect of services, not to

make assumptions that monitoring, performance management or intervention was

the responsibility of others and to tackle challenges and barriers to building a positive

culture.

To align with territorial Health Boards and ensure that services are being effectively

scrutinised it is important to identify a system of quality management that will include

all activities of the overall management function that determine the quality of policy,

objectives, responsibilities and their implementation. ISO 900012 explains that a

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management system provides the means of establishing a policy and objectives and

the means to achieve those objectives. Actions associated with Quality Assurance

and Control can be found in Appendix A.

Quality Improvement

Improvement is defined as the application of a systematic approach that uses

specific techniques to improve quality. This can range from small-scale continuous

improvement at the frontline and support services through to large-scale and

complex major service change and transformation.

NHS 24 will focus as a priority on developing the culture of Quality Improvement as a

business as usual state for all staff. NHS 24 will utilise validated data to evidence the

requirement for improvement and to understand the issues being addressed. The

triangulation of evidence to support improvement should be drawn from quantitative

data and intelligence, qualitative evidence will be drawn from people’s views and

opinions and crucially observational data.

Through the application of improvement science, including the Model for

Improvement Plan, Do, Study, Act (PDSA) cycles to test and evaluate changes, and

the POTI (process, organisation, technology, information) model which can be used

to define the scope and scale of transformational change required, NHS 24 can

minimise unnecessary variation and deliver improvements that will be both scaleable

and sustainable. NHS 24’s Executive Management Team and Board are committed

to leading and promoting Quality Improvement and will dedicate the required time

and resources for delivery. The overarching ambition is for Quality Improvement to

be embedded, managed and conducted by clinicians, managers and frontline staff

with appropriate support. This is the beginning of a process where it is envisaged

that NHS 24’s commitment to an empowered workforce with a co-design and co-

relationship approach to enabling quality will be realised. Actions associated with

Quality Improvement can be found in Appendix B.

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A LEARNING SYSTEM AND SUPPORTING INFRASTRUCTURE

At the heart of the Healthcare Improvement Scotland Quality Framework lies a

learning system. This is supported by the philosophy of Demmings profound system

of knowledge13, where the principles of co-design and co-production supported by

building knowledge and understanding variation is key. NHS 24 is an organisation

that embraces this concept and strives to make a learning system the reality, and

where assurance and control processes are in place to highlight where things do not

work so well and can be improved. Key to a learning system is the identification of

individual and organisational learning which is embedded in a just culture, where the

overarching principles are improvement and development to deliver the best possible

services.

A quantitative and qualitative measurement system that enables learning about what

does and does not work will be developed, with processes in place that support the

appropriate use of evidence. Individuals, teams and directorates will be enabled to

work together, collaboration with partners will be explored, and systems will be

developed to identify and learn from good practice and achievements. To deliver the

highest quality services for the people of Scotland, the whole organisation requires to

work together as a single system in pursuit of this aim. No single part of the system

‘owns quality’ and fundamental to the approach NHS 24 is taking is collaborative

working across all directorates and all teams. All departments have a role to play in

supporting the delivery of services against the quality ambitions. Actions associated

with the Learning System can be found in Appendix C.

NHS 24 may wish to give consideration in the future to the creation of a Quality and

Safety function to offer NHS 24 a beneficial overarching non-operational arm with the

responsibility for the overall planning, delivery and management of Quality and

Safety. This modernising approach would align NHS 24 with other NHS Scotland

Health Boards. Proven successful examples can be found in Highland, Lanarkshire

and Lothian where visionary leadership ensures the quality approach is successfully

delivered to coordinate meaningful consistent, sustainable improvements and quality

of services. A Quality and Safety function would encompass all aspects of work

relating to standards, quality and safety of services delivered and should be

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independent to those who are delivering the services.

DELIVERING THE PLAN

The NHS 24 approach to quality and the principles and objectives set out in this

Quality Framework will underpin all aspects of delivery of the framework, progressing

through the appropriate governance structures prior to reporting to the Board.

NHS 24 will develop specific action plans to identify key deliverables to support the

delivery of the aims and actions as set out within the framework and appendices with

identified timelines, milestones, measures of success and action owners. These

plans will be underpinned by the organisation’s quality ambitions to deliver safe,

effective and person-centred care.

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APPENDICES

Appendix A - Quality Assurance and Quality Control Actions:

a. A Quality Data & Measurement Framework for NHS 24 will be developed

and implemented to promote a consistent approach to defining,

gathering, configuring, analysing and reporting data for the purpose of

Quality planning, Quality Control and Assurance or Quality Improvement

using a common infrastructure.

b. All data, for whatever purpose, are presented and interpreted using

agreed Measurement & Visualisation Standards.

c. An agreed set of Quality Indicators and associated measurement plans

are developed with stakeholders prior to commencing any service

change / transformation to demonstrate the impact of the change, and

any resulting improvement.

d. Service change / transformations are monitored and evaluated, using

agreed quality data collection tools.

e. Staff have access to, and use, best evidence to inform and improve

peoples’ health and care.

f. NHS 24 will use the Healthcare Improvement Scotland Quality

Framework to carry out regular self-evaluation of the quality of care

approach and will work collaboratively with Healthcare Improvement

Scotland and NHS Education Scotland in developing an external

assurance process.

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Appendix B - Quality Improvement Actions:

a. A range of approaches are utilised to enable service providers to

design and implement high quality systems of care.

b. Develop a workforce to deliver the highest quality of care, Staff

will be trained, have access to and use Quality Improvement

concepts / methods to scope and review existing processes to

better understand the system, identify variation and areas for

improvement

c. Quality Improvement science methodology and tools are used in

the development of change ideas and concepts for testing.

d. Data for improvement is used to evaluate impact of progress

against project aims.

e. Cost and efficiency savings should be boldly considered in the

remit of quality as part of the IHI Triple Aim14 of best population

health, quality of individual care and reduced/controlled cost per

capita of healthcare

f. Meaningful opportunities will be created for managers, staff and

stakeholders to work together on difficult challenges and NHS 24

will provide them will the tools and resources to find and

implement solutions to test radical innovations and small tests of

change

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Appendix C – Learning System and Infrastructure Actions:

a. NHS 24 will actively seek ways to celebrate good practices and share

learning from positive experiences

b. NHS 24 will continue to develop ways to meaningfully engage with

services users and staff to maximise quality and influence

improvement.

c. NHS 24 will further develop the framework for identifying, recording

and sharing organisational learning

d. NHS 24 will commit to developing meaningful continuous

professional development for staff, with increased face to face

engagement and feedback in order to promote the quality ethos.

e. Appropriately skilled staff from all directorates will work together to

support Quality Improvement initiatives and work which has been

established to deliver improvement in services. Opportunities for

cross directorate and partner working will be explored.

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ACKNOWLEDGEMENTS

Grateful thanks is offered to the Director of Quality and the Quality Directorate of

NHS Lanarkshire for their generous support and advice.

In developing this document NHS 24 consulted the Institute for Healthcare

Improvement Framework for Safe, Reliable and Effective Care.15 Which focuses on

the development of a learning system underpinned by leadership and accountability.

Please note an action plan associated with the framework will be developed and

implement based upon the actions outlined in Appendices A-C. This will include

timelines for delivery and owners, and will be monitored via the National Clinical

Group to provide assurance to the Clinical Governance Committee and NHS 24

Board

If you would like us to consider producing this report in a different format please

phone us on 0800 22 44 88. If you have a textphone dial 18001 0800 22 44 88.

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REFERENCES

1. NHS 24 Delivering person-centered health & care services 24/7: Our strategy

2016-2021

2. The Quality Framework Draft Edition - Evaluating and improving healthcare (2017)

http://www.healthcareimprovementscotland.org/our_work/governance_and_assuranc

e/quality_of_care_approach/quality_framework.aspx

3. Quality Management System: A 90-day innovation cycle

http://www.healthcareimprovementscotland.org/previous_resources/policy_and_strat

egy/quality_management_system.aspx

4. NHSScotland Healthcare Quality strategy (2010)

http://www.gov.scot/resource/doc/311667/0098354.pdf

5. European Foundation for Quality Management (EQFM) Excellence Model

http://www.efqm.org/the-efqm-excellence-model

6. Realistic Medicine: The Chief Medical Officers Annual Report (2014)

http://www.gov.scot/Resource/0049/00492520.pdf Accessed 05.10.2016

7. The Vale of Leven report (2014)

http://www.valeoflevenhospitalinquiry.org/report.aspx Accessed 25.08.2016

8. Scotland's Digital Health and Care Strategy: enabling, connecting and

empowering

http://www.gov.scot/Publications/2018/04/3526 Accessed 29 October 2018

9. Juran, J.M., 2003. Juran on leadership for quality. Simon and Schuster

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10. The Measuring and Monitoring of Safety, Drawing together academic evidence and

practical experience to produce a framework for safety measurement and monitoring. The

Health Foundation (2013)

https://www.health.org.uk/publication/measurement-and-monitoring-safety

11. The Mid Staffordshire NHS Foundation Trust Public Inquiry (2013)

http://webarchive.nationalarchives.gov.uk/20150407084003/http://www.midstaffspubl

icinquiry.com/

12. ISO 9000 Family – Quality Management, https://www.iso.org/iso-9001-quality-

management.html

13. Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L. and Provost,

L.P., 2009. The improvement guide: a practical approach to enhancing

organizational performance. John Wiley & Sons

14. The IHI Triple Aim,

http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx

15. Institute for Health Improvement, White Paper - A Framework for Safe, Reliable,

and Effective Care http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-

Safe-Reliable-Effective-Care.aspx